The Benefit Place
Summary of Coverage - Exclusions
The following general summary of the services not covered under this plan may vary according to the state in which the insured obtains coverage:
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Charges for services or supplies not listed in the covered medical services provision; charges for complications of treatment or surgery resulting from an excluded service or procedure; charges for complications resulting from the covered person leaving an inpatient or outpatient facility against the advice of the covered person’s physician.
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Charges for drugs or medications.
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Free treatment or charges that, in the absence of our coverage, the covered person is not required to pay.
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Charges for missed appointments, and provider administrative fees.
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Charges for the services of a standby physician except in limited circumstances.
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Charges for treatment of the covered person’s intentionally self-inflicted illness or injury, whether sane or insane.
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Charges for treatment of an illness or injury caused by or contributed by: caused by or contributed by: (a) employment; (b) the participation in the military service; (c) war or act of war, (d) commission of a felony; or (e) participation in illegal activities or riot.
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Charges for treatment of an illness or injury that occurs while the covered person has been under the influence of illegal narcotics or non-prescribed controlled substance.
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Charges for injury sustained while: (a) participating in any intercollegiate sport: (b) traveling to or from such sport as a participant; or (c) participating in any practice or conditioning program for such sport.
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Charges for cosmetic treatment of surgery and any complications arising from such treatment or surgery.
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Charges for hearing aids; eyeglasses; contact lenses; eye exams; eye refraction; eye surgery for correction of refraction error, orthotics or corrective shoes; repairs to or prosthetic devices; or routine foot care.
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Charges for normal pregnancy or childbirth, cesarean sections or routing newborn nursery care; genetic testing, counseling or therapy including but not limited to, amniocentesis and chorionic villi testing; intrauterine or fetal treatment or surgery; abortion; except as provided in the Complications of Pregnancy Provision; treatment of sexual dysfunction; transsexual surgery; infertility diagnosis and treatment; oocyte retrieval; artificial insemination; in-vitro fertilization; surrogate pregnancy; fees associated with sperm banking; and sterilization or reversal of sterilization.
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Charges for treatment, medications or hormones and any other treatment or surgery for weight control or obesity.
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Charges for treatment of psychiatric conditions of substance abuse.
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Charges for dental treatment including dental braces or appliances to a sound tooth.
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Charges for services rendered by or supplies purchased from a member of the covered person’s extended family or a person residing with the covered person.
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If the covered person is eligible for Medicare, that part of any charge for which a benefit would be paid under Medicare to a person enrolled under Parts A and B of Medicare, regardless of whether such person actually was enrolled. This does not apply when the benefits of this plan are, by law, primary to those of Medicare.
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Charges for treatment, repair or removal of the tonsils or adenoids.
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Charges for services rendered and supplies received which are not for treatment of illness of injury.
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Charges for living expenses; and travel or transportation expenses.
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Charges for treatment of chronic pain disorders; biofeedback; aversion therapy; custodial care; help programs; services of a non-physician surgical assistant; services rendered by a masseur, masseuse or rolfer; health club membership fees or exercise equipment.
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Charges for experimental or investigational services.
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Charges incurred outside of the United States or its possessions or Canada.
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Charges for which we are unable to determine our liability because you failed to provide us with the necessary information.
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Charges incurred during a hospital confinement prior to surgery unless the admission is medically necessary for an emergency.
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The first $500 of otherwise covered charges not authorized in accordance with the Benefit Management Program provision or any expense for an organ transplant if the procedure was not authorized prior to any organ evaluation, testing or donor search.
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Charges incurred after coverage terminates.
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Charges incurred for a condition for which there is other liability insurance providing medical payments or medical expense coverage.
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See policy for complete explanations of exclusions.
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